37. During a blood transfusion, a client reports a throbbing headache, chills, and nausea. What ordered drugs should a nurse prepare for administration? Select all that apply.
37. During a blood transfusion, a client reports a throbbing headache, chills, and nausea. What ordered drugs should a nurse prepare for administration? Select all that apply.
Test-Taking Tip
Recognize the difference between a hemolytic reaction (ABO incompatibility) and an allergic reaction to the donor protein (likely a hereditary component to this reaction).
Content Area: Adult Health, Pharmacology; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Pharmacological and Parenteral Therapies/Blood and Blood Products
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Answer 1 is incorrect because epinephrine is the first line of treatment for an allergic reaction. This client is experiencing a hemolytic reaction. Epinephrine blocks the effects of the histamine released during an allergic reaction. Answer 2 is correct because the client is experiencing hemolytic shock and sodium bicarbonate will be needed to reverse metabolic acidosis. Answer 3 is incorrect because theophylline is a bronchodilator, and would improve wheezing, but it would not reverse the antibody effects and the potential for shock, which is causing the signs and symptoms. Answer 4 is correct because hydrocortisone will be given to control the effects of the antigen-antibody reaction that has occurred from apparent ABO incompatibility. Answer 5 is correct because this client is experiencing a hemolytic reaction that can progress to septic shock. A vasopressor will be needed to maintain the blood pressure.
